Annuloplasty Ring and Holder Combination

ABSTRACT

An annuloplasty ring holder includes an angled post for improved visibility and access by the surgeon. The post may be configured to be adjusted in angle and rotation. The ring holder can include a relatively open lower template, including relatively narrow extending radial arms with short, generally arcuate ring-retaining distal portions. The invention includes placements of suture holes and cutting wells which, in combination with improved suture routing, afford the user improved access to cutting the suture that is used to retain the annuloplasty ring to the holder. Another annuloplasty ring and ring holder combination disclosed includes a generally triangular-shaped ring and a generally T-shaped holder. The ring holder has a base portion forming the top of the T shape and engaging against a first segment of the ring, with a radial arm extending from the base portion and forming the post of the T. The radial arm engages against a junction between two segments of the ring.

RELATED APPLICATIONS

The present application is a continuation of U.S. patent applicationSer. No. 11/515,466, filed on Sep. 1, 2006, which is acontinuation-in-part of U.S. patent application Ser. No. 11/386,429,filed on Mar. 22, 2006, now U.S. Pat. No. 7,575,595, which claimspriority from U.S. Provisional Application Ser. No. 60/664,875, filed onMar. 23, 2005, the contents of which are expressly incorporated hereinin their entirety. This application is related to U.S. PatentPublication No. 2008/0058924, entitled “Saddle-Shaped AnnuloplastyRing,” the contents of which are expressly incorporated herein in theirentirety.

FIELD OF THE INVENTION

The present invention relates generally to medical devices, andparticularly to repair of heart valves using annuloplasty rings.

BACKGROUND OF THE INVENTION

In vertebrate animals, the heart is a hollow muscular organ having fourpumping chambers: the left and right atria and the left and rightventricles, each provided with its own one-way valve. The natural heartvalves are identified as the aortic, mitral (or bicuspid), tricuspid,and pulmonary, and are each mounted in an annulus comprising densefibrous rings attached either directly or indirectly to the atrial andventricular muscle fibers.

Heart valve disease is a widespread condition in which one or more ofthe valves of the heart fails to function properly. Diseased heartvalves may be categorized as either stenotic, wherein the valve does notopen sufficiently to allow adequate forward flow of blood through thevalve, and/or incompetent, wherein the valve does not close completely,causing excessive backward flow of blood through the valve when thevalve is closed. Valve disease can be severely debilitating and evenfatal if left untreated.

Valve disease involving the mitral valve often involves secondary mitralregurgitation (MR), a complication of end-stage cardiomyopathy which isthe backflow of blood from the left ventricle (LV) to the left atrium(LA) resulting from imperfections in the mitral valve. When the mitralvalve allows blood to flow backward into the left atrium, the leftventricle must pump progressively harder to circulate blood throughoutthe body, which in turn promotes congestive heart failure (CHF).

Various surgical techniques may be used to repair a diseased or damagedvalve. One method for treating defective valves is through repair orreconstruction. One repair technique that has been shown to be effectivein treating incompetence is annuloplasty, in which the effective sizeand/or shape of the valve annulus is modified by securing a repairsegment, such as an annuloplasty ring, around the heart valve annulus.For example, the valve annulus may be contracted by attaching aprosthetic annuloplasty repair segment or ring to an interior wall ofthe heart around the valve annulus. The annuloplasty ring is designed tosupport the functional changes that occur during the cardiac cycle:maintaining coaptation and valve integrity to prevent reverse flow whilepermitting good hemodynamics during forward flow.

The annuloplasty ring typically comprises an inner substrate, oftenformed from a metal (such as stainless steel or titanium) or from aflexible material (such as silicone rubber or Dacron cordage), which istypically covered with a biocompatible fabric or cloth to allow the ringto be sutured to the heart tissue. Depending on a particularapplication, annuloplasty rings may be stiff or flexible, may be splitor continuous, and may have a variety of shapes, including circular,D-shaped, C-shaped, saddle-shaped, and/or kidney-shaped. Examples areseen in U.S. Pat. Nos. 5,041,130, 5,104,407, 5,201,880, 5,258,021,5,607,471, 6,187,040, and 6,805,710, the contents of which areincorporated herein by reference in their entirety. Many annuloplastyrings are formed in a plane, but some rings are generally non-planar.Such non-planar rings can be saddle-shaped, and/or bowed along variousportions, such as being bowed along their anterior or straight side toconform to the desired shape of the annulus at that location.

Implanting of annuloplasty rings can be a difficult procedure.Currently-available methods include open-heart surgery and so-calledminimally-invasive procedures. One particular difficulty is firmlyholding the ring during the surgery. It is possible to implant rings byclamping the ring with forceps and/or the surgeon's fingers, but in manycircumstances a specifically tailored annuloplasty ring holder isdesirable. Examples of annuloplasty ring holders are depicted in U.S.Pat. Nos. 5,350,420; 5,683,402; and 6,749,630, the contents of which areincorporated herein by reference in their entirety.

Using a standard atriotomy approach to the mitral valve for repair, thesurgeon does not generally achieve straight-on access to the mitralvalve annulus. Instead, the surgeon often sees and accesses the valvefrom an angle. Therefore, when the sutures are placed in theannuloplasty ring and it is “parachuted” down to the annulus, the ringand holder must be reoriented to sit flat against the annulus. Inminimally-invasive (MIS) approaches to the mitral valve, theannuloplasty ring must be passed through a relatively small port intothe chest. This can be complicated by the bulk of some holders, so insome instances a surgeon simply removes the holder from the ring priorto “parachuting” the ring down the sutures and onto the valve annulus.However, the removal of the entire holder from the ring can make controlof the annuloplasty ring more difficult.

Another issue is visibility of the ring and valve annulus during theimplantation procedure. Some holders block significant portions of thesurgeon's view, which can make the surgical procedure more difficult. Toenhance visibility, some holders make use of transparent and/ortranslucent materials. Some holders use a so-called “window” approach,wherein openings are positioned in the template portion of the holder.The openings serve as windows in the holder template through which theuser can view the surgical procedure. Examples of such holders aredescribed in U.S. Pat. Nos. 5,683,402 and 6,749,630, the contents ofwhich are incorporated by reference herein in their entirety.

Another issue is securing the ring to the holder in a releasable butsecure manner. Many holders use multiple retaining sutures to secure aring to the holder. In order to release the ring from the holder, theuser severs the retaining sutures. Increasing the number of sutures cancause the ring to be more securely held to the holder, but can increasethe steps necessary for the surgeon to release the ring from the holder.Additionally, the positioning of the retaining sutures is important inthat the user must be able to access and sever the sutures to releasethe ring from the holder. Many prior ring holders made use of suturewells located at various positions about the holder, with the locationof such wells corresponding to locations about the ring including theposterior and anterior portions of the ring. During implantationprocedures, some of these locations may be difficult for a surgeon toaccess in order to sever the suture.

Accordingly, there has been a need for an improved apparatus, system,and method to implant an annuloplasty ring. The present inventionsatisfies one or more of these needs.

SUMMARY OF THE INVENTION

The present application is generally described with respect to its usein the repair of the mitral valve, which regulates blood flow from theleft atrium (LA) to the left ventricle (LV). However, the inventioncould also be applied to repair of other valves, such as the tricuspidor aortic valves.

The invention includes several features for annuloplasty ring holdertechnology. One feature is the application of reduced structuralelements on the holder, including radial arms and other structures, toincrease the visibility for the user during the implantation procedure.In addition to reducing the structural elements, placing the structuralelements of the holder (including the post) toward the outer regions ofthe holder, which in turn places those elements toward the outer regionsof the central opening bounded by the annuloplasty ring when the ring isattached to the holder, also provides enhanced visibility andaccessibility of the ring as well as of the heart valve and otherphysiological structures underneath the ring.

In one embodiment of the invention, the holder includes a lower templateforming a generally T-shaped configuration, with a radial arm formingthe post of the T and a base template section, with two wing-likeportions, forming the top bar of the T. The base template section isplaced against a first portion of the ring, which may be an anteriorportion configured for placement on the valve annulus adjacent ananterior leaflet. The base template section extends only partially intothe area bounded by the ring, and preferably extends only approximatelyto or short of the geometric center of the bounded area. The handle postcan be secured to the base template section so that the handle post iswell away from the geometric center of the ring bounded area. The radialarm extends from the base template section across the ring bounded areato an opposing portion of the ring. If the base template section isplaced against an anterior portion of the ring, the radial arm mayextend from the base template section to a central or other section ofthe posterior portion of the ring.

A holder and ring combination according to an embodiment of theinvention includes a generally triangular-shaped ring, with the ringhaving three segments joined adjacent their ends to form the generallytriangular shape. The holder has a first base portion that runsgenerally parallel to one of the three segments. The holder has a radialarm that extends from the base portion to engage a junction between theother two segments. These other two segments are thus unsupported anduncovered by the holder for substantially their entire lengths exceptfor their end portions.

Another feature is the use of an angled handle post, which is eitherfixed or adjustable. The angled handle post may also be rotationallyadjustable about the longitudinal axis of the holder. Angling the handlepost with respect to the plane of the annulus permits the user greatervisibility during an implantation procedure. The surgeon does notgenerally achieve direct straight-on access to the valve annulus, butinstead typically sees and accesses the valve from an angle. By applyingan angle to the post with respect to the plane of the annulus, a moreintuitive orientation of the ring, and parachuting of the ring down ontothe valve annulus, can be achieved.

Another feature is the improved placement of suture wells, and improvedsuturing techniques that facilitate severing the suture lines andassembly of the device. In one embodiment the suture wells are placedtoward the outer regions of the holder, away from the handle post, sothat the user can more easily access the suture wells to cut theretaining suture lines. The suture wells are desirably positioned so asto enhance visibility and accessibility of the suture wells to thesurgeon or other user. Moreover, the suture routing provides widerattachment points for greater stability of the ring on the holder.

Other features and advantages of the present invention will becomeapparent from the following detailed description, taken in conjunctionwith the accompanying drawings which illustrate, by way of example, theprinciples of the invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 depicts a perspective view of an assembly having a ring, ringholder, and handle according to an embodiment of the invention;

FIGS. 1A and 1B depict perspective views of an assembly having a ringholder and handle according to an embodiment of the invention;

FIGS. 2A-2C are various views of the annuloplasty ring from FIG. 1;

FIGS. 3A-3F are various views of the ring holder from FIG. 1;

FIG. 4 is a top view of a ring holder according to an embodiment of theinvention;

FIG. 5 is a top view of a ring holder according to an embodiment of theinvention;

FIG. 6 is a side view of a ring holder according to an embodiment of theinvention;

FIG. 7 is a perspective view of a portion of a ring holder according toan embodiment of the invention;

FIG. 8 is a perspective view of a portion of a ring holder according toan embodiment of the invention;

FIG. 9 is an exploded perspective view of the portion of the ring holderdepicted in FIG. 8;

FIG. 10A is a perspective view of ring and ring holder according to anembodiment of the invention;

FIG. 10B is a perspective view of ring and ring holder according to anembodiment of the invention;

FIG. 11 is a side view, in cross-section, of a portion of a ring andring holder according to an embodiment of the invention;

FIGS. 12A and 12B are perspective and top views, respectively, of a ringand ring holder according to an embodiment of the invention;

FIGS. 13A through 13H are perspective, back, top, bottom, front, frontin cross section, side, and side in cross section views, respectively,of the annuloplasty ring holder from FIGS. 12A and 12B;

FIGS. 14A through 14E are top, bottom, front elevational, rearelevational, and side elevational views, respectively, of theannuloplasty ring from FIGS. 12A and 12B; and

FIGS. 15A-15E are various perspective views of an annuloplasty ring andholder from FIGS. 12A and 12B being used to implant a ring in a patient.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

One embodiment of the invention is depicted in FIG. 1. The device 10comprises a holder 12 and annuloplasty ring 14. The holder 12 has alower template portion 16 secured to a handle post 18. In the embodimentdepicted, the handle post 18 has a proximal end 20 and distal end 22,with the distal end 22 secured to the template portion 16. The handlepost proximal end 20 includes an attachment assembly 24 by which ahandle 26 can be removably secured to the handle post 18. The handle 26includes a proximal portion 26 a, a middle portion 26 b, and a distal(attachment) portion 26 c. The distal portion 26 c is configured tocooperate with the attachment assembly 24 in order to secure the handle26 to the handle post 18. The middle portion 26 b of the handle may bemalleable, thereby permitting a surgeon to adjust (via bending) thehandle to a configuration convenient for the particular application andsurgeon.

Attachment and removal of the handle 26 to and from the handle post 18are depicted in FIGS. 1A and 1C. The handle 26 can be secured to thehandle post 18 by snapping the handle distal portion 26 c into theattachment assembly 24. Removing the handle 26 is accomplished bygripping the holder 12 while pulling the handle 26.

FIGS. 2A-2C are plan, front elevational, and side elevational views,respectively, of an annuloplasty ring 14 from FIG. 1. The ring 14 isgenerally oval-shaped about a major axis 30 and a minor axis 32. Thering has a posterior portion 34, an anterior about a major axis 30 and aminor axis 32, with a maximum height dimension 33 measured parallel tothe minor axis 32. The ring has a posterior portion 34, and anteriorportion 36, and sides 38, 40. A mid-section 42 of the posterior portion34 of the ring 14 bows upward and inward. The elevation above a datumplane 44 is seen in FIG. 2B, while the magnitude of the inward bow ofthe mid-section 42 is seen in FIG. 2A. The sides 38, 40 also bow upwardas indicated in FIG. 2B. Finally, the anterior portion 36 bows upwardand inward. The mid-section 42 forms a plateau 46 in the Z-directioncentered about the minor axis 32 as seen in FIG. 2B. The ring can beformed from various materials, such as stainless steel, titanium,Stellite, cloth, etc. The choice of materials and specific design of thering depend on the particular application. In the embodiment of FIGS.2A-2C, the ring has a specific shape. However, other shapes are alsowithin the scope of the invention. The ring may be relatively flexibleor relatively stiff, or may be a combination of stiff and flexibleportions.

FIGS. 3A-3F depict the holder 12 from FIG. 1 in greater detail. Theholder 12 includes a central base portion 50. First and second arms 52a, 52 b extend from the central base portion 50. At the distal ends 54a, 54 b of the first and second arms 52 a, 52 b are ring securingportions 56 a, 56 b against which one or more portions of anannuloplasty ring can be positioned. The holder 12 has a maximum width53 and a maximum height 55. In the embodiment depicted, the securingportions 56 a, 56 b include generally arcuate segments which areconfigured to engage side portions 38, 40 of the annuloplasty ringdepicted in FIGS. 2A-2C. In the embodiment of FIGS. 3A-3F, the generallyarcuate segments are relatively short, having a height 57 less than themaximum height 55 of the holder 12.

In the embodiment of FIGS. 3A-3F, a posterior knob portion 58 isconfigured to engage a posterior portion 34 of the annuloplasty ring 14,and an anterior knob portion 60 is configured to engage an anteriorportion 36 of the annuloplasty ring 14. The knob portions 58, 60 provideadditional support to the annuloplasty ring 14. Although the embodimentdepicted in FIGS. 3A-3F has knob portions 58, 60 that lack any sutureholes through which sutures can pass to secure the ring to the knobportions, such sutures and knob portion suture holes are within thescope of the invention.

The holder 18 can be formed from various materials, or combinations ofdifferent materials, depending on the particular application. In oneembodiment, the holder 12 is formed from a clear polysulfone. The holder12 may also include markers for visibility under surgical conditions,such as radiopaque markers. In the embodiment depicted in FIG. 3D, theholder 12 includes a radiopaque marker 51 embedded within the handlepost 18. Such a radiopaque marker can be formed of various materials,such as polyphenylsulfone with 14% radiopaque bismuth subcarbonate.

In the embodiment depicted in FIGS. 3A-3F, the only structure leadingfrom the central base portion 50 out to the annuloplasty ring is the twoarms 52 a, 52 b and the knob portions 58, 60. By limiting the size (whenviewed by the user from above) of the structure within the area enclosedby the ring (i.e., the central base portion 50, the arms 52 a, 52 b, andthe knob portions 58, 60), the visibility afforded the user during thesurgical procedure is improved over products having greater mass withinthe area enclosed by the ring.

Depending on the particular application, including the type of ringbeing delivered and whether the ring is rigid or flexible, one or bothof the knobs 58, 60 and/or one or both of the arms 52 a, 52 b may beeliminated to further enhance the visibility. For example, in theembodiment depicted in FIG. 4, the knobs have been eliminated in favorof the arms 52 a, 52 b. The central base portion 50 has a maximum height59 and maximum width 61. In the embodiment of FIG. 5, the arms have beeneliminated in favor of the knobs 58, 60. The knobs 58, 60 each havesuture holes 62 and corresponding cutting wells 64 through which suturesmay pass to secure the ring to the knobs and holder. The knobs 58, 60narrow toward their distal ends to distal widths 63, 65.

The central base portion 50 may also be further reduced in size, as maythe knobs 58, 60 and arms 52 a, 52 b. The arms and/or knobs may also berelocated to different locations on the central base portion 50,depending on the particular application.

Another aspect of the invention is the positioning of the handle postwith respect to the ring. By applying an appropriate angle to the handlepost of the holder with respect to the ring, the plane of the ring willnaturally be parallel to the plane of the annulus. This allows for moreintuitive orientation of the ring, and parachuting of the ring down tothe annulus without reorientation. In the embodiment depicted in FIG. 6,the longitudinal axis 65 of the handle post 18 is positioned at an angle66 from a vertical plane 68 normal to the datum plane 70 of the ring 14.In the particular embodiment depicted, the angle is approximately 11degrees, although other angles are also within the scope of theinvention. For example, angles between 10 and 15 degrees may be usefulfor ring holders. Other angles can also be selected, depending on theparticular application.

The optimal angle may not be constant for every patient or surgeon. Forexample, different patients often have different physicalcharacteristics of their respective mitral valves. Also, differentsurgeons may use slightly different approaches to the mitral valve, ormay have certain preferences with respect to viewing angles, etc.

A single-pivot structure can be helpful in adjusting the angle asdesired. As depicted in FIG. 7, a handle post 18 having a proximalportion 18 a and a distal portion 18 b, with the distal portion 18 bsecured to the central base portion (not shown) of the holder 12. Theproximal portion 18 a can be pivoted with respect to the distal portion18 b, which permits a user to adjust the handle post angle to achievethe optimal angle for the specific application. The proximal portion 18a has a toothed fitting 72 a configured to interlock with acorresponding toothed fitting 72 b on the distal portion 18 b. Eachtoothed fitting has a corresponding pin hole 74 a, 74 b at its center. Areleasable compression pin 76 is configured to pass through the pinholes 74 a, 74 b. With the compression pin 76 tightened in place, itholds the toothed portions 72 a, 72 b in engagement, maintaining a fixedangle between the proximal portion 18 a and distal portion 18 b of thehandle post 18. With the compression pin 76 loosened, the user canadjust the angle between the proximal portion 18 a and distal portion 18b of the handle post 18, and then lock the pin 76 into its tightenedconfiguration in order to fix the proximal portion 18 a and distalportion 18 b at the desired angle.

In another embodiment of the invention, the holder may include theability to change not just the holder angle but also the rotationalposition of part of the holder with respect to the central base portion.In the embodiment of FIGS. 8 and 9, the handle post 18 includes a distalportion 18 b fixed to the central base portion 50. A handle postproximal portion 18 a is rotationally secured to the distal portion, sothat the proximal portion 18 a can rotate about the holder longitudinalaxis 78. The rotation of the proximal portion 18 a can be controlled byconventional methods, such as having a releasable lock (not shown) thatselectively prevents rotation.

To permit adjustment of the angle between the ring datum plane and aportion of the post, the handle post 18 has an additional proximalstructure 80 that can be adjusted in angle 81 with respect to the ringdatum plane and holder longitudinal axis 78. The additional proximalstructure 80 can be releasably and/or adjustably secured to the rest ofthe handle post 18 so that the angle 81 can be modified as the userdesires. Conventional structures can be used to accomplish this feature.

In the embodiment of FIGS. 8-9, a rotational ball and retainer structureis used. The additional proximal structure 80 includes a ball 82configured to cooperate with a corresponding recess 84 in the handlepost distal portion 18 b. An adjustable housing 85, which also forms thehandle post proximal portion 18 a, is configured to hold the ball 82against the recess 84. The adjustable housing 85 includes a slit 90,which facilitates removal of the adjustable housing from the additionalproximal structure 80 and also permits the additional proximal structure80 to be rotated to relatively extreme angles. The adjustable housing 85can be screwed onto the handle post distal portion 18 b viacorresponding threading 86, 88 on the handle post distal portion 18 band in the adjustable housing 85. By loosening (i.e., unscrewing) theadjustable housing 85 from the handle post distal portion 18 b, a userwill loosen the additional proximal structure 80 and permit adjustmentof the angle and rotation thereof. Once the desired angle and rotationare achieved, the user can tighten the adjustable housing 85 onto thehandle post distal portion 18 b, which will secure the additionalproximal structure 18 at the desired angle and rotation.

Another embodiment involves a similar ball and housing structure to thatdepicted in FIGS. 8 and 9, but with the ball structure positioned on thehandle post and the adjustable housing on the additional proximalstructure. In this embodiment, the ball is attached to the holder andthe housing is lengthened and turned upside down to become part of thehandle and/or additional proximal structure. There is an additionalstructure that threads inside of the housing. At the distal end of thisstructure there is mechanism that allows a user to thread the structureinto or out of the housing and thus move the structure relative to thehousing. At the other end of the structure there is a recess thatconforms to the shape of the ball. With this embodiment, a user cantighten or loosen the housing by rotating the handle and/or additionalproximal structure. This permits a surgeon to make an adjustment toangle and rotation at a distance (i.e. by turning a knob at the end ofthe handle).

In minimally invasive surgery (MIS) approaches to the mitral valve, theannuloplasty ring must be passed through a relatively small port intothe chest. This can be complicated by some holders, which can interferewith introducing the annuloplasty ring into the chest. Depending on theparticular application, the current invention's feature of adjusting thehandle post angle and/or rotational position can also allow easierpassage of the ring and holder into the chest cavity. Such adjustmentcan occur before and/or during the surgical procedure. For example, asurgeon may select an initial rotation and angle during initial surgicalprocedures, then select another rotation and/or angle for introductionof the ring and holder through the chest wall, and then select stillanother rotation and/or angle for final placement of the ring.

Another feature of the invention is depicted in FIG. 10A, which depictsa holder 12 and ring 14. Suture holes 100 are positioned at distal ends54 a, 54 b of the arms 52 a, 52 b, with corresponding suture wells 102positioned on the arms 52 a, 52 b. In the embodiment of FIG. 10, thesuture wells 102 are positioned on the arms 52 a, 52 b to correspondwith the sides 38, 40 of the ring 14. Restraining sutures 104 passthrough the suture holes 100 and suture wells 102. The suture wells 102are configured to provide an easily accessible location for the surgeonto cut the suture 104 passing therethrough. Due to the structure of theparticular ring 14, which is relatively short along its minor axis whencompared to its length along the major axis, the areas of the ring 14and holder 12 corresponding to the ring sides 38, 40 are generally theareas which are most easily accessible to the surgeon during animplantation procedure. By positioning the suture wells 104 at theseareas (which are furthest away from the holder central portion andpost), the invention facilitates the ease by which the surgeon can severthe restraining sutures in order to release the ring 14 from the holder12.

A similar embodiment is depicted in FIG. 10B, which has a holder 12 andring 14. The holder 12 of FIG. 10B has a generally solid lower templateportion 16 (instead of the arms 52 a, 52 b depicted in FIG. 10A). In theembodiment of FIG. 10B, the suture wells 102 are positioned on the lowertemplate portion 16 to correspond with the sides 38, 40 of the ring 14.Restraining sutures 104 pass through the suture holes 100 and suturewells 102. The suture wells 102 are configured to provide an easilyaccessible location for the surgeon to cut the suture 104 passingtherethrough.

In the embodiments depicted in FIGS. 10A and 10B, there are only twosuture wells. However, other numbers of suture wells, from one (1) andup, are within the scope of the invention, depending on the particularnumber of sutures. As a general rule, fewer sutures and correspondingsuture wells leads to greater ease in cutting the sutures. By limitingthe number of sutures and/or suture wells, and by positioning the suturewells at those areas that are easiest to access, the inventionfacilitates the ease by which the surgeon can sever the restrainingsutures.

Another feature of the invention is an improved suture routing approach.The approach is depicted in FIG. 11, wherein a single piece of sutureline 104 passes in the depicted pattern through the various suture holes100, across the suture well 102, and through portions of the ring 14.For one suture hole 100 a, the suture line 104 passes through the suturehole 100 a, then is looped around a flange or other edge of the holder14, and then passes back through the suture hole 100 a (in the samedirection that it passed through previously), thereby providingresistance to the suture slipping with respect to the holder 106. Thesuture 104 is tied to itself. In the embodiment depicted, a doublesquare knot 108 is used to secure the suture 104 to itself. Note thatother knots are also within the scope of the invention. The describedsuture routing provides wider attachment points for greater stability ofthe ring on the holder, without increasing the likelihood of a highsuture pull-out resistance.

FIG. 12A depicts a further embodiment of the invention, wherein a ringdelivery system 110 includes a holder 112 having an annuloplasty ring114 secured thereto. The particular annuloplasty ring holder 112 isconfigured to fit the particular ring 114 depicted, which is itselfsized and configured for placement on or in the mitral valve. However,other holder configurations and sizes are also within the scope of theinvention, including holders configured to hold annuloplasty ringshaving different sizes and configurations, and holders for ringsconfigured to placement in other valves, e.g., tricuspid valves, etc.

The holder 112, which is depicted in FIGS. 13A-13H without the ring 114,has a lower template portion 116 secured to a handle post 118. In theembodiment depicted, the handle post 118 has a proximal end 120 anddistal end 122, with the handle post distal end 122 secured to thetemplate portion 116. The handle post proximal end 120 includes anattachment assembly 124, similar to that depicted in the embodiment ofFIGS. 1, 1A-1B, and 3A-3F, by which a handle can be removably secured tothe handle post 118. The holder 112 can be used with a handle such asthat depicted in FIGS. 1 and 1A-1C, or with other handles, depending onthe particular application.

The holder 112 has a lower template portion 116 that is formed from twoparts: a base template section 126 and a radial arm 128, which togetherform a generally “T”-shaped structure with the radial arm 128 formingthe base of the T and the base template section 126 forming the crossbar of the T. The base template section 126 includes a middle portion130 positioned adjacent the handle post distal end 122 and first andsecond wing portions 132, 134 extending from opposing sides of thehandle post distal end 122. As seen in FIGS. 13A, 13B, 13E, and 13F, thefirst and second wing portions 132, 134 curve downward at their distalends. The base template section 126 includes a notch 136 configured toabut against the ring 114, with the notch 136 forming a generallycontinuous path passing along the outer/lower areas of the middleportion 130 and wing portions 132, 134.

The radial arm 128 includes a radial arm distal end 138 with a ringsecuring portion 140 thereon. The ring securing portion 140 includes asmall notch 142 which is configured to engage against the ring 114,similar to the longer notch 136 of the base template section 126.

The holder 112 includes suture holes 144 adjacent to correspondingsuture wells 146, positioned at the distal portion of the radial arm 128and the distal portions 148, 150 of the template wing portions 132, 134.As depicted in FIG. 12A, restraining sutures 152 pass through the sutureholes 144 and suture wells 146. The suture wells 146 are configured toprovide an easily accessible location for the surgeon to cut the suture152 passing therethrough. Due to the structure of the particular ring114, the areas of the ring 114 and holder 112 corresponding to thetemplate wing portion distal ends 148, 150, as well as the radial armdistal end 138, are generally the areas which are most easily accessibleto the surgeon during an implantation procedure. By positioning thesuture wells 146 at these areas (which are furthest away from the holdercentral portion and post), the invention facilitates the ease by whichthe surgeon can sever the restraining sutures 152 in order to releasethe ring 114 from the holder 112.

In the embodiments depicted in FIG. 12A-12B and 13A-13H, there are threesuture wells 146. However, other numbers of suture wells, from one (1)and up, are within the scope of the invention, depending on theparticular number of sutures, the shape and size of the ring, etc. As ageneral rule, fewer sutures and corresponding suture wells leads togreater ease in cutting the sutures. By limiting the number of suturesand/or suture wells, and by positioning the suture wells at those areasthat are easiest to access, the invention facilitates the ease by whichthe surgeon can sever the restraining sutures.

The combination of features of the holder 112 and ring 114 togetherprovide an improved ring delivery system. As seen in FIG. 12B, theparticular ring 114 is generally in the shape of an isosceles triangle,with the ring 114 having three generally straight segments 115 a, 115 b,115 c that are connected toward their ends to form the triangular shape.One of the generally straight segments 115 a forms an anterior portionof the ring 114, while the remaining generally straight segments 115 b,115 c form a posterior portion of the ring 114. The base portion 126 isgenerally straight and elongated, and with its wings 132, 134 runsgenerally parallel with one of the generally straight segments 115 a. Inthe particular embodiment depicted, the (anterior) generally straightsegment 115 a is adjacent to and supported by the holder 114 foressentially the entire length of the generally straight segment 115 a.The radial arm 128 extends to engage a junction between the othergenerally straight segments 115 b, 115 c. These other generally straightsegments 115 b, 115 c are thus left generally free of the holder 114along their lengths except for their end portions. The suture wells 146of the holder 112 are positioned adjacent the end portions of thegenerally straight segments 115 a, 115 b, 115 c, which correspond to thecorners of the generally triangular shape of the particular ring 114depicted.

In the particular holder embodiment depicted in the cross-sectionalviews of FIGS. 13F and 13H, the holder 112 includes a hollow opening 149passing through the lower template portion 116 and into the lowerportion of the handle post 118. As depicted in FIG. 13H, the holder 112may include a radiopaque marker 151 or other visualization referencethat can enhance the visibility of the holder 112 under fluoroscopy orother visualization methods. In the particular embodiment of FIG. 13H,the radiopaque marker 151 extends from within the handle post 118 andinto the hollow opening 149.

FIG. 12B is a top view of the system 110, viewed from a position similarto that a surgeon or other user will encounter during an annuloplastyring installation procedure. The combination of relatively a relativelynarrow base template section 126 (which in the particular embodimentdepicted comprises two narrow wing portions 132, 134) and the generallythin radial arm 128, provides enhanced viewing through the system 110via large open areas 154, 156 within the area 153 bounded by the ring114. In the particular embodiment depicted, the relatively narrow basetemplate section 126 is positioned adjacent the ring 114 along an outerportion of the bounded area 153, and does not extend into the boundedarea 153 far enough to extend over the ring geometric center 157. Theradial arm 128 does extend over the geometric center 157, but issufficiently narrow that visibility is still maintained through most ofthe bounded area 153. By positioning the handle post 118 adjacent anouter edge of the holder 112 and away from the geometric center 157 ofthe area 168 bounded by the ring 114, and more specifically (in theparticular embodiment depicted) adjacent the outer edge 158 of themiddle section of the middle portion 130 of the base template section126, the handle post 118 and any handle that might be attached theretoare positioned generally out of the way, thereby providing enhancedviewing of and access to the surgical site by the surgeon or other user.

The invention can include annuloplasty rings of various construction andconfiguration. In one preferred embodiment, an annuloplasty ring of thepresent invention comprises a continuous ring body which may be made ofmetal, such as a titanium alloy, or other appropriate material. Atubular sleeve or outer band, which may be formed from silicone, isaround the ring body. Finally, a tubular fabric covering around thesilicone sleeve provides an anchoring platform for sutures or otherattachment devices such as staples. The fabric covering is typicallyDacron (polyethylene terephthalate). The tubular fabric covering aroundthe silicone sleeve provides an interface for securing the annuloplastyring to the mitral annulus, although other interfaces are contemplated.For example, rings having outward hooks or barbs are known in the art.

FIGS. 14A through 14E depict the ring 114 from FIGS. 12A and 12B,separate from the holder, in greater detail. Similar rings are disclosedin U.S. Patent Publication No. 2008/0058924, entitled “Saddle-ShapedAnnuloplasty Ring” and filed concurrently herewith, the contents ofwhich are expressly incorporated by reference herein. Other rings thatcould be used with the system and holder of the invention are disclosedin pending U.S. Pat. No. 7,294,148, entitled “Annuloplasty Ring forMitral Valve Prolapse” and filed on Apr. 29, 2004; and in U.S. PatentPublication No. 2006-0129236, entitled “Annuloplasty Ring for MitralValve Prolapse” and filed on Feb. 2, 2006, the contents of each of whichare hereby incorporated by reference in their entirety.

FIGS. 14A-14E illustrate the completed ring 114 so that a fabriccovering is all that is visible. The annuloplasty ring 114 is depictedin the top view of FIG. 14A with a modified oval shape (closed)surrounding a central opening 153. The ring 114 is oriented about acentral flow axis 170. The flow axis 170 defines an upward direction anda downward direction, corresponding to the top and bottom of the pagerelative to the ring 114 as seen in FIGS. 14C-14E. The downwarddirection corresponds to the direction of blood flow through the mitralvalve annulus from the left atrium to the left ventricle, such that downis synonymous with the inflow direction and up is synonymous with theoutflow or regurgitative direction of the valve. Looking along the flowaxis 170 in FIG. 14A, the ring 114 has a major axis 172 perpendicular toa minor axis 174, the major and minor axes 172, 174 being perpendicularto the flow axis 170. It should also be understood that the “flow axis”here may not necessarily be the center of the volumetric flow throughthe annulus, but is instead orthogonal to the major and minor axes 172,174, and therefore defines the gross direction of flow. The ring 114also has a geometric center 157 in plan view, which is defined as thegeometric center of the ring bounded area 153. Depending on the geometryof a particular ring, a flow axis may or may not align with a geometriccenter. In the particular embodiment of FIG. 14A, the flow axis 170 ispositioned some distance from the geometric center 157.

A major axis dimension 176 is shown extending horizontally across theinterior of the ring 114 the plan view of FIG. 14A. Likewise, a majoraxis dimension 178 is shown extending across the interior of the ring114. In one preferred embodiment, the ratio of the minor axis dimension178 to the major axis dimension 176 is about 3.5:4 (87.5%). Other ratiosare also within the scope of the invention.

A bottom view of the ring 114 is depicted in FIG. 14B. The bottom of thering 114 includes a marker in the form of a colored thread 179 toindicate that this side of the ring 114 is intended to lie against thevalve annulus when implanted.

For purpose of further definition, a pair of trigone markers T1 and T2is shown on the ring 114 corresponding to the approximate location ofthe fibrous trigones of the mitral annulus when the ring 114 isimplanted. An anterior segment 180 extends around an anterior portion ofthe ring 114 between the trigone markers T1, T2. When the ring 114 isimplanted, the anterior segment 180 will coincide with the anterioraspect of the mitral valve annulus. The anterior segment 180 is showngenerally straight in the midsection when viewed from the top in FIG.14A or bottom in FIG. 14B, but has an upward bow that can be seen in theanterior end view of FIG. 14D. Other shapes of the anterior segment arealso within the scope of the invention, including curved or bowedportions to better conform to the anterior aspect of the native annulus.

The remainder of the ring 114 aside from the anterior segment 180between the trigone markers T1, T2 will be termed the posterior portion182, and is shown broken up into three sequential segments denoted P1,P2, and P3 (in series counter-clockwise from the first trigone markerT1), with the dividing line between P1 and P2 indicated as P12, and thedividing line between P2 and P3 indicated as P23. The precise angulardividing line between these three segments P1, P2, P3 is notstandardized, though they are intended to generally correspond to thethree visible cusps of the posterior leaflet of the mitral valve. In anexemplary embodiment, the three segments P1, P2, P3 are approximatelyequal in angular dimension, and the middle segment P2 is symmetric aboutthe minor axis 174. It should be noted that annuloplasty rings areshaped and marked so as to be orientation-specific, such that theanterior segment is adapted to be implanted against the anterior aspectof the mitral annulus, and the same with the posterior portion.

The annuloplasty ring 114 has a modified D- or oval shape in plan viewbecause of an outward bow 184 within the middle segment P2 of theposterior portion of the ring. Stated another way, the middle segment P2of the posterior portion 182 of the ring 114 has an outward curve(convexity) more pronounced than adjacent sections (which may also beconvex or relatively straight). The outward bow 184 thus bulges outwardfrom the adjacent sections as compared to a conventional 3:4 ratio“D-shaped” annuloplasty ring such as the relaxed shape of aCarpentier-Edwards Physio® annuloplasty ring available from EdwardsLifesciences of Irvine, Calif. (www.edwards.com). In the particularembodiment depicted, the ring 114 includes a posterior portion centralmarker 185 designating the center point of the posterior portion 182.

As mentioned above, the outward bow 184 preferably results in aminor-major axis dimensional ratio of 3.5:4 (87.5%), although thepresent invention encompasses other rings, including in anotherpreferred embodiment rings having an outward bow 184 that producesratios of between about 3.3:4 (82.5%) and 4:4 (100%).

It is important to note that although the minor axis dimension 178 mayincrease relative to conventional D-shaped rings, the major axisdimension 176 can remain substantially the same. Furthermore, althoughthe outward bow 184 is shown within the middle segment P2 of theposterior portion 182 of the ring, the entire section of the posteriorportion that is posterior of the major axis 172 may be affected. Thatis, the outward bow 184 may extend into one or both of the first andthird segments P1 and P3 of the posterior portion 182. In a preferredembodiment, however, the annuloplasty ring 114 only diverges from aconventional oval- or D-shaped ring (such as the Carpentier-EdwardsPhysio® ring) within the middle segment P2. In an exemplary embodiment,the angular extent of the outward bow 184 as measured about the centralaxis 170 is between 90-130 degrees, and more preferably about 128degrees.

In conjunction with the outward bow 184, the posterior portion 182 ofthe annuloplasty ring 114 also includes a posterior upward bow 186 seenin FIG. 14C. The term “upward bow” refers to either an upward divergencefrom a planar ring, or an upward divergence from a so-called“saddle-shaped” ring. Therefore, the present invention encompasses bothplanar and saddle-shaped rings having an outward and upward posteriorbow.

A height 188 of the posterior upward bow 186 is indicated in FIG. 14Cand desirably exceeds about 3 mm, preferably more than about 4 mm, andmost preferably between about 3-10 mm. The posterior upward bow 186 mayor may not be formed in the ring 114 around the same angular extent asthe outward bow 184. In a preferred embodiment, the outward bow 184spans a smaller angular extent than the posterior upward bow 186,although they may start and end at the same location around the ring114. Likewise, both the outward bow 184 and posterior upward bow 186 aredesirably centered along the minor axis 174, although one or both may beasymmetrically offset. It should be noted that in the particularembodiment depicted the upward bow in the anterior segment 180 issomewhat higher than the posterior upward bow 186, as seen in FIGS.14C-14D.

Note that other ring configurations are within the scope of theinvention. The ring can be formed from various materials andcombinations thereof, such as stainless steel, titanium, Stellite,cloth, etc. The choice of materials and specific design of the ringdepend on the particular application. Various ring shapes may beemployed. The ring may be relatively flexible or relatively stiff, ormay be a combination of stiff and flexible portions.

FIGS. 15A-15E depict an implantation procedure using the holder 112 toimplant a ring 114 to a heart valve according to the current invention.In FIG. 15A, a handle 190 is depicted being removably secured to theholder 112 and ring 114 combination. FIG. 15B depicts the holder 112 andring 114 adjacent a heart valve 192 having an anterior leaflet 194 and aposterior leaflet 196. Sutures 198 are passed through the fibrous mitralannulus 200 of the heart valve 192 at a distance of about 2 mm from theleaflet edge. Some of the sutures 198 are also passed through ring 114,and particularly through the anterior portion 180 of the ring 114.Others of the sutures 198 will be passed through the posterior portion182 of the ring 114, but in the particular embodiment of FIG. 15B thisis not depicted as having yet happened. Note that the particular orderin which sutures or sets thereof are passed through the ring can varydepending on the particular application, including the preferences of aparticular surgeon or other user. For example, a user might pass theposterior-adjacent sutures through the ring first, etc.

As the operation progresses, all sutures 198 are passed through both thefibrous mitral annulus 200 and the ring 114. In FIG. 15C, the sutures198 are held in tension while the ring 114 is slid down (sometimesreferred to as “parachuting down”) the sutures 198 until the ring 114 isseated above the mitral valve 192 and against the mitral valve annulus200.

Note that in FIGS. 15A and 15C, the handle 190 is depicted removablysecured to the holder 112, but in FIG. 15B no handle is depicted. Thelack of a handle is FIG. 15B is merely for clarity in the figure, anddoes not necessarily mean that no handle will be present during thatportion of the procedure. Depending on the particular application,including the preference of a particular user, the handle could be leftoff the holder from the start so that it is not used at all in theprocedure. The handle could also be attached to the holder for just oneor more parts of the procedure, e.g., the initial passing of the firstset of sutures through the ring, or the handle could be attached to theholder throughout the entire procedure.

If the surgeon or other user is satisfied with the initial placement ofthe ring 114 against the mitral valve annulus 200 (i.e., the placementafter the ring 114 is slid down the sutures 198 to the mitral valveannulus 200), the user ties off the sutures 198 in order to tightlysecure the ring 114 to the mitral valve annulus 200. As the ring 114 istightened into place via the sutures 198, the mitral valve annulus 200is re-shaped to improve coaptation and effectuate the valve repair.

To remove the ring 114 from the holder 112, the user will cut theretaining sutures 152 that hold the ring 114 to the holder 112. Ascalpel 202 or other cutting instrument is passed into the cutting wells146 to cut the retaining sutures 152, as depicted in FIG. 15D. With theretaining sutures 152 cut, the holder 112 can be pulled away from thering 114. Note that in an exemplary embodiment the retaining sutures 152are connected via knots or other restraints to the holder 112, so thatwhen the retaining sutures 152 are cut their severed ends will remainconnected to the holder 112. Accordingly, when the retaining sutures 152are cut and the holder 112 pulled away from the ring 114, the retainingsutures 152 will be removed from the ring 114 along with the holder 112.

FIG. 15E depicts the ring 114 secured to the valve annulus 200 and withthe holder removed. The sutures 198 have been tied off securely and anyexcess suture material removed. The heart valve 192 is repaired, withthe anterior leaflet 194 and posterior leaflet 196 appearing to have agood coaptation line 204. Valvular competency can be tested by variousmethods, including methods known in the art such as injecting salineinto the left ventricle through the mitral orifice and then verifyingwhether the coaptation line is visible, regular, and symmetrical.Intraoperative echo can also be used in assessing valvular competencyand the quality of the repair.

Note that the ring implantation can be performed in conjunction withother valve repair procedures, such as a quadrangular resection of theposterior leaflet performed to remove excess cusp tissue. For example,in the embodiment depicted in FIG. 15E, the posterior leaflet 196 hasbeen resected, excess tissue removed, and the remaining posteriorleaflet portions sutured together, with the resulting leaflet repairsuture 206 depicted running through the middle of the posterior leaflet196.

While the invention has been described with reference to particularembodiments, it will be understood that various changes and additionalvariations may be made and equivalents may be substituted for elementsthereof without departing from the scope of the invention or theinventive concept thereof. For example, while the invention isspecifically discussed in application with mitral valve repair, it hasapplicability in other areas where it is desired to repair valves andsimilar structures. In addition, many modifications may be made to adapta particular situation or material to the teachings of the inventionwithout departing from the essential scope thereof. Therefore, it isintended that the invention not be limited to the particular embodimentsdisclosed herein, but that the invention will include all embodimentsfalling within the scope of the appended claims.

1. An annuloplasty ring and holder assembly combination, comprising: anannuloplasty ring having a continuous periphery with an elongatedgenerally oval-shape in plan view defining a major axis and acorresponding major axis dimension across a widest span, and a minoraxis perpendicular to the major axis and across the middle of theannuloplasty ring, and a corresponding minor axis dimension, the majoraxis dimension being substantially longer than the minor axis dimension;and a ring holder, comprising: an upstanding post having an attachmentassembly to which a handle can be removably secured; a lower templateportion secured to the post and including first and second narrow armsextending outward in generally opposite directions from the post andterminating in first and second ring securing segments having sutureholes, each of the ring securing segments having an arcuate shapeoriented to be convex outward and being narrow in a radial direction soas to form a T-shape with the associated narrow arm, and wherein thering securing segments are spaced apart a distance approximately equalto the major axis dimension so that the ring securing segments eachengage and conform to an inner edge of the annuloplasty ring, whereinthe narrow arms and narrow arcuate ring securing segments leave open alarge portion of the area enclosed by the annuloplasty ring thusenhancing visibility therethrough; and restraining sutures between thering securing segments and the arcuate sides of the annuloplasty ringreleasably securing the ring holder to the annuloplasty ring.
 2. Thecombination of claim 1, wherein in plan view the annuloplasty ring has aposterior portion opposite an anterior portion both generally alignedwith the major axis, and arcuate sides generally aligned with the minoraxis, and wherein a mid-section of the posterior portion bows inwardtoward the anterior portion.
 3. The combination of claim 1, wherein inplan view the annuloplasty ring has a posterior portion opposite ananterior portion both generally aligned with the major axis, and arcuatesides generally aligned with the minor axis, and wherein a mid-sectionof the posterior portion bows inward toward the anterior portion andupward in a Z-direction perpendicular to both the major and minor axes.4. The combination of claim 3, wherein the lower template portionfurther includes a pair of knobs extending outward in generally oppositedirections from the post and generally perpendicular to the first andsecond narrow arms, each knob extending a distance so as to engage aninner edge of the anterior and posterior portions of the annuloplastyring, respectively.
 5. The combination of claim 4, further includingrestraining sutures between the each knob and the anterior and posteriorportions of the annuloplasty ring, respectively.
 6. The combination ofclaim 1, wherein the major axis dimension is more than twice as long asthe minor axis dimension.
 7. The combination of claim 1, wherein theannuloplasty ring comprises an inner titanium substrate and an outerbiocompatible fabric cover.
 8. The combination of claim 1, furthercomprising a handle releasably secured to the upstanding post, whereinthe post includes structure to adjust and fix the angle of attachment ofthe handle relative to the lower template.
 9. An annuloplasty ring andholder assembly combination, comprising: an annuloplasty ring having acontinuous periphery with an elongated generally oval-shape in plan viewdefining a posterior portion opposite an anterior portion both generallyaligned with a major axis, the continuous periphery having acorresponding major axis dimension across a widest span, the continuousperiphery further defining arcuate sides generally aligned with a minoraxis perpendicular to the major axis and across the middle of theannuloplasty ring, and a corresponding minor axis dimension, the majoraxis dimension being longer than the minor axis dimension, and wherein amid-section of the posterior portion bows inward toward the anteriorportion and upward in a Z-direction perpendicular to both the major andminor axes. a ring holder, comprising: an upstanding post having anattachment assembly to which a handle can be removably secured; a lowertemplate portion secured to the post and including first and secondnarrow arms extending outward in generally opposite directions from thepost and terminating in first and second arcuate segments oriented to beconvex outward and being spaced apart a distance approximately equal tothe major axis dimension so that the arcuate segments each engage andconform to an inner edge of the arcuate sides of the annuloplasty ring;a pair of knobs extending outward in generally opposite directions fromthe post and generally perpendicular to the first and second narrowarms, each knob extending a distance so as to engage a portion of theinner edge of the anterior and posterior portions of the annuloplastyring, respectively, the knobs being offset from each other in theZ-direction; and restraining sutures between the ring holder and theannuloplasty ring releasably securing the ring holder to theannuloplasty ring.
 10. The combination of claim 9, wherein restrainingsutures secure the arcuate segments to the arcuate sides of theannuloplasty ring.
 11. The combination of claim 9, wherein restrainingsutures secure each knob to the anterior and posterior portions of theannuloplasty ring, respectively.
 12. The combination of claim 9, whereinthe major axis dimension is more than twice as long as the minor axisdimension.
 13. The combination of claim 9, wherein the annuloplasty ringcomprises an inner titanium substrate and an outer biocompatible fabriccover.
 14. The combination of claim 9, further comprising a handlereleasably secured to the upstanding post, wherein the post includesstructure to adjust and fix the angle of attachment of the handlerelative to the lower template.
 15. An annuloplasty ring and holderassembly combination, comprising: an annuloplasty ring having acontinuous periphery with an elongated generally oval-shape in plan viewdefining a major axis and a corresponding major axis dimension across awidest span, and a minor axis perpendicular to the major axis and acrossthe middle of the annuloplasty ring, and a corresponding minor axisdimension, the major axis dimension being at least twice as long as theminor axis dimension; and a ring holder, comprising: an upstanding posthaving an attachment assembly to which a handle can be removablysecured; a lower template portion secured to the post and includingfirst and second arms extending outward in generally opposite directionsfrom the post and terminating in first and second securing segmentsspaced apart a distance approximately equal to the major axis dimensionso that the securing segments each engage an inner edge of theannuloplasty ring, each securing segment defining at least one suturecutting well therein; at least one restraining suture between eachsecuring segment and the engaged portion of the annuloplasty ring thatextends over the cutting well in the corresponding securing segment toreleasably secure the ring holder to the annuloplasty ring, whereinthere are no other restraining sutures than those that secure thesecuring segments to the annuloplasty ring.
 16. The combination of claim15, wherein a mid-section of the posterior portion bows inward towardthe anterior portion.
 17. The combination of claim 15, wherein amid-section of the posterior portion bows inward toward the anteriorportion and upward in a Z-direction perpendicular to both the major andminor axes.
 18. The combination of claim 17, wherein the lower templateportion further includes a pair of knobs extending outward in generallyopposite directions from the post and generally perpendicular to thefirst and second narrow arms, each knob extending a distance so as toengage an inner edge of the anterior and posterior portions of theannuloplasty ring, respectively, the knobs being offset from each otherin the Z-direction.
 19. The combination of claim 15, wherein theannuloplasty ring comprises an inner titanium substrate and an outerbiocompatible fabric cover.
 20. The combination of claim 15, furthercomprising a handle releasably secured to the upstanding post, whereinthe post includes structure to adjust and fix the angle of attachment ofthe handle relative to the lower template.